HomeMy WebLinkAboutPro's Car Care 7/10/2018Commonwealth of Massachusetts
Town of Mansfield
Board of Health
Town of Mansfield
6 Park Row
Mansfield, MA 02048
Permit to Operate a Food Service Establishment
Type: STREET FAIR -FAMILY FUN NIGHT
In accordance with Regulations promulgated under authority of Chapter 94, Section
305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:.
Whose place of business is:
PRO'S CAR CARE COMPLEX, INC. - FAMILY FUN NIGHT
NORTH MAIN STREET
PERSON(S) IN CHARGE:
Permit Expires: ,July 10, 2018
Food Fee:
License Number: FFN-21
WAIVED
BOARD OF HEALTH
MichaeCMcCCean, Chairman
FOR BOARD OF HEALTH USE ONLY
'fir 1
Date Received Date Inspected Approved By Permit # Issued
Mansfield Family Fun Night
Food Establishment Permit Application
Establishment Name: _ (� 0 1, �
C"CZ> CX, 0.(` Co n l C-.
Establishment Address:
Establishment Mailing Address (if different):
Establishment Telephone No:
Applicant Name & Title:U.
Applicant Mailing Address: - Applicant Ph ne Number;
o t
Applicant Email: PC: J cP'YI'1
Establishment Owned By;• An association
• Acorporation ✓
An individual
A partnership
Other least entit
Water Source: Town
Sewage disposal: Town
Days and Hours of Operation: 4PM to Midnight
Location: Street Fair
Establishment Type V-1 \ Snack 11���•. _ �; —�' �. 2Z �2
Food Operations:
(cilack all that apply)
PHF— potentially hazardous food(timeAernperatu& controls required)
Oefiniflons: Non-PHFs— non- potentially hazardous food (no time/temperature controls required)
RTE— ready -to -eat foods Ex, sandwiches, salads, muffins which need no furtherprocessing)
Distribution of Commercially Pre -Packaged candy or bottled drinks
❑ Preparation and distribution of popcorn, cotton candy, open hot and cold drinks.
❑ Distribution of foods that are cut up and served.
Other (Describe):
To be completed by the Board of Health
otal Permit Fee: FEE WAIVED
1, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food
establishment operation will comply with 105 CMR 590.000 and all other applicable law. i have been instructed by
the board of health on how t Otain pies of 105 CMR 590.000 and the federal Food Code.
Signature of Applicant: ��
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief,
have filed all state tax returns and paid state taxes required under law.
Signature of Individual or Corporate Name: F es% !f �— — `K
11)
TAX CERTIFICATION FORM
I certify under the penalties of perjury that 1, to my best knowledge and
belief, have filed all state tax returns and paid all state taxes required
under law.
�_ Qta< Cc, C.c,fe
Signature of Individual or Corporate Name
(7kd — a u 6 8 L/L/
"Social Security No. (Voluntan,/) or Federal
rdentiicationNumber
By; Corporate Officer (WR-atonj, if Applicable)
*This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will be subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law
Chapter 62C, section 49A.
as
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www,ntass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LelriblY
Business/Organization Name:_ C,ce e Cn.�1. Peel Z Y\ C
od^"r o
City/State/Zip; �l\J a\� Q-\e�j \Q Phone
Are y an employer? Check the appropriate box:
I. 1am a employer with _,50_ employees (full and/
or part-time).*
2: ❑ 1 am a sole proprietor or partnership and have no
employees working for mein any capacity.
[No workers' comp, insurance required]
3, ❑ We are it corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]'
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp, insurance rN.]
q
Business Type (required):
5. ❑Retail
6. E]Restaurant/Bar/Bating Establishment
7, ❑ Office and/or Sales (incl. real estate, auto, etc,)
8. ❑ Non-profit
9. ❑ Entertainment
10.0 Manufacturing
1 L❑ Health Care
'Any applicant that chwka box pl most also fill out tho seedon below showing meir workers' compensation policy mrormanon.
49f the corporate officers have exempted themselves, but the wsporation has other employees, a workers' compensation policy is requited and such an '
organization should check box #1.
f am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance CompanyNamed..�1SxUY`r�t
Insurer's Address: O b—{ \C WB
City/State/Zip: �m ' Q C � O \\b
Policy # or Self -ins. Lic, #-1 A a — 00 \0 %0 \S Expiration Date:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fno
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,Aader thepains and penalties ofperjury that the information provided above is true and correct.
=1
Official use only. Do not write in this area, to be completed by city or town offtciaL
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office
6.Other
Contact
Mansfield Board of Health
Waiver 2018 for Food Permit
Date � � —O-C� \\$
"Put the name of your restaurant on first line then sign the form.
We-, C-C r C `rt- � o \meµ 7iv\c_ request a waiver of the
Food Service Permit Fee for the following reason:
Thank you,
Family Fun Night 2018
Signature
Title
yi
Jane Doucette
From:
Debbie Leary <dleary@ProsCarCare.com>
Sent:
Wednesday, June 20, 2018 4:38 PM
To:
Jane Doucette
Subject:
ProsCarCare - family fun night application
Attachments:
Untitled_06202018_042647.pdf
Here is our completed application to hand out prepackaged candy at family fun night.
Please let me know if you need anything else.
Thanks!
Debbie Leary
The Pro's Car Care Complex
44-46 Chauncy St.
Mansfield, MA02048
p:508-339-4300 x.19
f:508-339-4344
dlearv@proscarcare.com
-----Original Message -----
From: dlearv@proscarcare.com [mailto:dleary@proscarcare.com]
Sent: Wednesday, June 20, 2018 4:27 PM
To: Debbie Leary <dlearv@ProsCarCare.com>
Subject: Scan from ProsCarCare
Please open the attached document.
1
AUTOMOTIVE INDUSTRIES COMPENSATION CORPORATION
WORKERS COMPENSATION AND EMPLOYERS LIABILITY COVERAGE
POLICY / CERTIFICATE INFORMATION PAGE
Automotive Industries Compensation Corporation
P.O. Box 1528
Springfield, MA 01101-1528
Policy / Certificate Number
Policy Year
Name of Member:
Mailing Address:
Street Address:
Additional Named Insureds:
Additional Workplaces:
8 Cottage Street, Mansfield, MA 02048
2.
3.
WC 001080-18
I/I/18'-1/1/19
The Pro's Car Care Complex Inc.
44-46 Chauncy Street
Mansfield, MA 02048
Date of Issue: 1/1/18
The certificate period is from January 1, 2018 (12:01 a.m. Standard Time) to but not including January 01, 2019 at
the Member's mailing address.
A. Workers' Compensation Coverage: Part One of the Certificate applies to the Workers' Compensation Law
of the Commonwealth of Massachusetts.
B. Employers' Liability Coverage: Part Two of the Certificate applies to the workplace(s) listed in item 1.
The limits of our liability under Part Two are:
Bodily Injury by Accident: $500,000 each accident
Bodily Injury by Disease: $500,000 certificate limit
Bodily Injury by Disease: $500,000 each employee
C. This certificate includes these endorsements and schedules: See Schedule.
The contribution for this certificate will be determined by our Manuals of Rules, Classifications,
Rates and Rating Plans. All Information required is subject to verification and change by audit.
Total Estimated Annual Contribution: See Classification Page attached.